JMIR Publications

ABSTRACT

Background:

Ethnic minority populations exhibit disproportionately high rates and poor control of type 2 diabetes mellitus (T2DM). eHealth tools have the potential to facilitate the cultural adaptation and tailoring of T2DM education to improve diabetes knowledge and management.

Objective:

a) To develop an adaptable Interactive lifestyle Assessment, Counseling and Education (I-ACE) software to support dietitian-delivered lifestyle counseling among ethnic-minority patients with T2DM; b) To evaluate its effect on diabetes-related dietary knowledge and management compared to standard lifestyle advice (SLA) in a randomized controlled trial (RCT).

Methods:

The I-ACE software was developed in consultation with experienced clinical dieticians and an endocrinologist. It incorporates evidence-based dietary and physical activity recommendations and educational materials. The features and behavioral change techniques include: quantitative lifestyle (dietary intake and physical activity) assessment and simulation, individually-tailored education and recommendations, motivational interviewing, the Pareto approach to achieving maximum impact with minimum change, goal-setting, and tracking progress. For the unblinded pilot RCT, 50 overweight/obese Arab adults (aged 40-62 y) with poorly-controlled T2DM were recruited from local primary care clinics and randomly assigned to receive 4 in-person, dietician-delivered counseling sessions over the course of 6 months either: 1) using the I-ACE tool (experimental arm), or 2) using standard lifestyle advice (SLA) methods (comparison arm). All outcome assessments were face-to-face. Diabetes-related dietary knowledge (primary outcome) was measured at baseline, 3, 6, and 12 months. Lifestyle behaviors, anthropometric parameters and HbA1c were measured before, during and after the intervention. Multiple linear regression and repeated-measures linear mixed models were used to compare change in study outcomes, and explore time trends in between- and within-group change.

Results:

Twenty-five participants were enrolled in each arm, of whom 24 and 21 completed the final assessment of the primary outcome in the I-ACE and SLA arms, respectively. DM-related lifestyle knowledge increased more rapidly in the I-ACE than the SLA arm (P for study arm*time interaction=.023). Added sugar intake was lower in the I-ACE than SLA arm at 12 months (mean±SE difference: -1.9±0.9% of total energy; P=.050). Within the I-ACE arm, the mean±SE differences in added sugar and dietary fiber intakes from baseline to 12 months were -2.6±1.0% of total energy (P=.025) and 2.7±0.0 g/1000 kcal (P=.003), respectively. The odds of engaging in any leisure physical activity at 12 months in the I-ACE vs SLA arms tended to be higher, but did not reach statistical significance (OR: 2.8; 95% CI: 0.7-11.6; P=.157). Both arms exhibited significant reductions in HbA1c (P for change over time<.001).

Conclusions:

Use of the culturally-adapted I-ACE software in a 6-month, 4-session dietician-delivered lifestyle counseling intervention improved the efficiency of lifestyle education, compared to SLA, among low-SES, ethnic minority patients with T2DM. This pilot trial provides justification for conducting a large-scale trial to evaluate its effectiveness and applicability in routine clinical care among ethnically diverse populations. Clinical Trial: ClinicalTrials.gov NCT01858506